Healthcare Provider Details

I. General information

NPI: 1922089192
Provider Name (Legal Business Name): MERRILL S WISE III M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/07/2005
Last Update Date: 02/17/2020
Certification Date: 02/17/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5050 POPLAR AVE SUITE 800
MEMPHIS TN
38157-0101
US

IV. Provider business mailing address

5050 POPLAR AVE SUITE 800
MEMPHIS TN
38157-0101
US

V. Phone/Fax

Practice location:
  • Phone: 901-276-2662
  • Fax: 901-274-2033
Mailing address:
  • Phone: 901-276-2662
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RS0012X
TaxonomySleep Medicine (Internal Medicine) Physician
License Number41144
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code2080S0012X
TaxonomyPediatric Sleep Medicine Physician
License Number41144
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: